Discharge from hospice alive

Paula Span recently wrote about hospice as a shield against unwanted medical treatments that provided the space for an elderly Medicare beneficiary to get better. The irony is that the family she writes about had to choose the option associated with imminent death to be able to take their mother home and allow her to receive competent care that her adult children could trust; eventually, she was discharged alive from hospice. Work that I did with colleagues at Duke shows that around 15% of Medicare beneficiaries who begin hospice are discharged alive (85% of Medicare beneficiaries choosing hospice used such care continuously until their death, an average of 50 days later; median 15 days, Group 1 below).

Read more of this post

Sen. Coburn: for unelected health boards before he was against them

Ezra Klein has an interview with Senator Tom Coburn that focuses on health care reform. Lots could be said about the interview, but I want to focus on what I see as the hypocrisy displayed by Sen. Coburn in his criticism of the Independent Payment Advisory Board (IPAB) that will be created if the Affordable Care Act is implemented. In the interview with Klein, Sen. Coburn says:

The reason I object to IPAB is you’ve got someone between the patient and the physician, and that can never be in the best interest of the patient.

The most shocking thing to me about Sen. Coburn’s consistent demonization of IPAB as a “rationing board”  is the fact that a bill (Patients’ Choice Act) that he co-sponsored and introduced on May 20, 2009 contained two unelected boards (IPAB is also quite weak; another post). That means that key Republicans supported unelected health boards a full month before the first House committee reported out HR3200. I have written tons on this issue specifically, and about Sen. Coburn’s Patients’ Choice Act generally (here, herehere, herehere, here, here, here), including some favorable things. I guess I am just naive, but this level of hypocrisy still shocks me.

Below is a post I wrote in May 2011 that focused on Rep. Paul Ryan, another co-sponsor of the PCA; just insert Sen. Coburn’s name as you read; they have behaved similarly on this issue.

Read more of this post

Private insurance and the NHS

Bob Watcher has a great post on the relationship between the NHS and private health insurance that jives with my understanding of how the two work together based on my post-doc at the University of Manchester in the mid-1990s, and my interest in that system ever since (h/t Brad Flansbaum, on twitter @BradleyFlansbau). Go read the post for a description of the many subtle details. A few big picture thoughts on the NHS and what it means for the U.S.:

  • All citizens have a stake in the NHS running as well as possible since they all use the NHS for primary care (everyone using the NHS is the best quality control program possible).
  • They explicitly acknowledge a tiered system and embrace the idea that those with private insurance or enough money can choose to go outside the NHS for specialty care to avoid waits, etc. This is often understood as helping to relieve pressure on the public system.
  • Access to the cheaper part of the system is easy, but much harder to the more expensive part.
  • They invented the system for themselves; it wasn’t imposed on them.

When Americans peer in and imagine “copying” that system, we rightly say “that won’t work here!” Of course it won’t, it is their system constructed by them for them; we have to come up with our own way of acknowledging limits and running the system. It is a matter of how we will ration, not if, but we do not seem to be able to acknowledge this and have a forthright conversation about how we will deal with this reality. It is interesting and even useful to look at how other systems work, especially to understand how incentives function in practice, but in the end, but we cannot and should not copy another nation’s health care system. We have to figure out how to make our system work for us.


Explicit v. implicit rationing-ctd.

A few more interesting papers on explicit v. implicit rationing in the spirit of continuing the conversation.

  • David Mechanic with a defense of implicit rationing in the BMJ (1995), along with some comparisons as he sees them between the NHS and managed care in the U.S. circa early 1990s.
  • Len Doyal making the case for explicit rationing, also in the BMJ (1997).
  • Joanna Coast in the same issue as the Doyal paper arguing against explicit rationing, in favor of implicit BMJ (in 1997).

These are short, clear papers. Lots more that you could read; check references of these papers and papers that have cited them.


Improving Medicare Coverage Policy

The Urban Institute and the Robert Wood Johnson Foundation have a new policy brief (summary) on Medicare enhancing the quality and efficiency of the program by improving its coverage policy (what care and services are covered for beneficiaries).

This is in keeping with Medicare’s programmatic “triple aims” they note:

  • improve patients’ experience of care
  • improve population health
  • reduce the rate of increase in per capita costs

Medicare has a mostly passive coverage policy, and the brief notes that much could be done to change this within existing authority. Since its creation, Medicare has been authorized to cover and pay for:

…services that are reasonable and necessary for diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

In practice, coverage decisions are typically deferred to patients and physicians with regional claims processing contractors approving care; however, these processors are mostly judged on efficiency and speed of processing claims and remitting payment to providers. There are some Medicare-wide coverage decisions made, called National Coverage Determinations (NCD) but these are rare, and inconsistent in the sense that it is often unclear why a NCD is issued in one area but not in another. This leads to:

The coverage process as currently applied does not prevent ineffective, unproven and/or harmful technologies from widespread adoption in Medicare, fails to identify and promote broad use of effective and high-value services…

The brief provides five recommendations to improve this situation:

  • Strengthening the evidence base and putting it to use in coverage policy, including extensive use of so-called “coverage with conditions” that would expand the available evidence-base
  • Increasing the use of comparative effectiveness research
  • Improving consistency in coverage policy
  • Explicitly considering costs in coverage policy
  • Adopting a general strategy of “least costly alternative” pricing/payment/coverage in specific clinical circumstances

I wrote yesterday that we need to make Medicare a more active purchaser of health care, and this brief lays out practical ways to move in that direction. In perhaps the understatement of the year, the authors (all former CMS officials) note the barriers:

Even when CMS has strong, scientific evidence that casts doubt on whether a technology or service effectively improves patient health and well-being, progress has stalled, in part because of a political environment in which evidence-based policy-making meets strong resistance from affected stakeholders